! ! PROJECT(SUMMARY/ABSTRACT( The clinical and financial burden of heart failure (HF) among older adults in the United States is high, with over 400,000 hospitalizations and $30 billion in spending annually. After a decade of steady improvement in short- term mortality among older adults hospitalized with HF, mortality within 30 days of hospital discharge is now increasing in this population. Little is known, however, about the factors driving this concerning trend. This study proposes to use administrative and qualitative data to evaluate patient, hospital, and policy level factors that explain rising mortality. In Aim 1, we will use Medicare data to determine if increasing clinical and/or social risk among older adults hospitalized with HF, or worsening hospital care quality, explain recent trends in mortality. In Aim 2, we will examine whether the Hospital Readmissions Reduction Program (HRRP) - a federal policy that intended to improve HF care by financially penalizing hospitals with high 30-day readmission rates ? has incentivized inappropriate post-discharge care strategies (i.e. avoiding indicated readmissions) that have been associated with increased mortality. Our preliminary data suggest that the rise in mortality is being driven by patients with HF who are not readmitted to the hospital, providing initial support for this hypothesis. In Aim 3, we will use semi-structured physician interviews to understand if their decision-making regarding the care of HF patients has changed since HRRP. In addition, we will interview patients with HF to explore their awareness and perception of this policy. These interviews will also be used to gather preliminary data on potential strategies to improve post-discharge HF care. The overarching goal of this proposal is to understand why short-term mortality among older adults with HF is rising in the United States, which may have significant clinical and policy implications. The first two aims of this analysis will inform whether more resources should be allocated to sites that care for clinically high-risk or socially disadvantaged populations and if current federal policies (HRRP) should be redesigned or eliminated. The third aim will lay the foundation for future research to develop and test novel strategies, based on physician and patient preferences, to improve post-discharge HF care. This research will be accomplished in the setting of a comprehensive career development program designed to provide Dr. Wadhera, an early career investigator and cardiologist, with the skills needed to become an independent investigator in cardiovascular medicine and health policy. His long-term career goal is to use large datasets at the population level, and qualitative methods at the individual level, to comprehensively evaluate the impact of health policies on cardiovascular care and outcomes. An outstanding mentoring team and advisory committee of established clinical investigators in the fields of cardiovascular medicine, outcomes research, health policy, and advanced biostatistical and qualitative methods will guide Dr. Wadhera in his transition to independence over the course of the award period. !